Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Integrated Care 24 (IC24) NHS111 and out-of-hours service in Norfolk on 23 March 2017.

The service was inspected in March 2016. The inspection report was unrated and focussed on Safe and Well Led domains only. Following that inspection we issued several requirement notices to the provider to improve the service. These requirement notices related to Regulations 12 (safe care and treatment), 17 (good governance), 18 (staffing) and 19 (fit and proper persons employed). We followed these notices up during this inspection to see whether sufficient improvements had been made.

Following the inspection on 23 March 2017,overall the service is rated as Good.

Our key findings were as follows:

• The provider had a clear vision which focussed on quality and safety.
• There were systems in place to help ensure patient safety through learning from incidents and complaints about the service.
• The service was consistently meeting National Quality Requirements and locally agreed key performance indicators.The primary care centres where patients were seen had good facilities and were equipped to meet the needs of patients. Vehicles used for home visits were clean and well equipped.
• We found that the service was well-led and managed by an effective senior management team and board of directors, and their values and behaviours were shared by staff.
• The service worked with other organisations and with the local community to develop services.
• NHS 111 staff were supported in the effective use of NHS Pathways. Call review and audit was regular and robust in its application.
• The service shared experience reports with the clinical commissioning group (CCG) on a regular basis which contained information on complaints, feedback from professionals, feedback from patients, incidents and accolades.

However, there was one area of practice where the provider should make improvements.

• Record details of recruitment and induction processes for clinical staff effectively in line with Schedule Three of the Health and Social Care Act 2008.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We carried out a focussed inspection with 48 hours’ notice at Integrated Care 24 (IC24) NHS 111 and Out-of-Hours Service on 16 March 2016.

The inspection focussed on safety and leadership at the service and took place following information of concern that had been highlighted to CQC.

Overall, we found that a number of key improvements needed to be made in order to ensure that people always received a safe effective service. However, action already taken by the new leadership indicated that the service is capable of making these improvements.

We found that:

• Systems and processes to help prevent patients being put at risk of harm were not always in place. For example, some nurses triaging patients were found to have undertaken tasks without evidence of them having had the appropriate training.
• There were delays in patients accessing both the 111 and the GP out of hours services.
• Although staff were clear about reporting incidents, near misses and concerns, scope for ongoing learning and/or improvement as a result of any incident was limited.
• Systems to record whether recruitment procedures had been followed were ineffective, meaning the service was unable to demonstrate whether staff were appropriately qualified and security checked.
• Inspectors found medicines that were out of date in some areas of the GP out-of-hours service.

However we also found:

• The service was able to identify areas for staff development and learning, as appropriate and effective clinical audits were in place.
• NHS 111 staff followed call procedures, to triage public telephone calls for medical care and emergency medical services, that helped them make safe and effective decisions when speaking to patients needing assistance.
• Reviews and audits of calls to the service were regular and robust.

CQC has told the provider it must:

• Ensure all out-of-hours staff who triage patients have been adequately trained to make clinical decisions by telephone and have been assessed as competent to do so. In addition, protocols and guidelines must be implemented to guide staff to make safe and appropriate decisions with regard to how people’s needs are assessed and dealt with.
• Prioritise ongoing work to investigate and tackle the causes of delays relating to patient care.
• Ensure medicines held at primary care centres are within the manufacturers’ recommended expiry dates and make sure there is an effective process for managing this.
• Put systems in place to ensure that staff files and recruitment procedures are effectively recorded.
• Undertake Disclosure and Barring Service checks for all staff in a timely and orderly manner.
• Ensure sufficient and appropriately trained staff are present at all primary care centres and that contingency arrangements for staff to follow are agreed for when gaps in GP cover arise.

The provider should make the following improvements:

• Learning relating to incidents should be shared with all relevant staff to encourage a culture of on-going improvement.
• Staff should always use the correct prescription pads when prescribing medicines.
• The provider should ensure all staff receive timely mandatory training and are supported in undertaking this.
• The provider should take action to ensure all staff are aware of who the safeguarding leads are within the service.
• All controlled drugs should be ordered from a wholesaler using the correct form, in line with Regulation 14 of the Misuse of Drugs Regulations 2001.
• Ensure a robust process is in place for monitoring clinical equipment, to make sure that it is fit for purpose.

This service is rated as Good overall. (Previous inspection March 2017 – Good overall, Requires Improvement in Safe)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Integrated Care 24 Limited – Norfolk and Waveney (IC24) on 21 June 2018.

At this inspection we found:

• The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
• The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated people with compassion, kindness, dignity and respect.
• Patients could access care and treatment from the service within an appropriate timescale for their needs.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Consider formal chaperone training for staff performing the role.
• Consider how the service strategy of matching capacity and demand is communicated to non-clinical staff.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice